Methods for analysis of molecular events

ABSTRACT

Methods and compositions are provided for detecting the presence of nucleic acid sequence variants in a subpopulation of nucleic acid molecules in a biological sample. These methods are particularly useful for identifying individuals with mutations indicative of cancer.

RELATED APPLICATIONS

[0001] This application claims priority to, and the benefit of U.S. Ser. No. 60/357,585, filed Feb. 15, 2002, the disclosure of which is incorporated by reference herein.

FIELD OF INVENTION

[0002] The invention relates to methods for detection and identification of genetic events in a biological sample. Methods of the invention are useful for disease detection and diagnosis.

BACKGROUND OF THE INVENTION

[0003] Many diseases are thought to be associated with genomic instability. Specific nucleic acid variations, such as mutations, insertions, deletions and other alterations can serve as valuable markers for a variety of diseases, including certain types of cancer. For example, mutations in the BRCA genes have been proposed as indications for breast cancer, and mutations in the p53 cell cycle regulator gene have been associated with numerous cancers, especially colorectal cancer. Other diseases that are linked with genomic instability include, for example, sickle cell anemia, phenylketonuria, hemophilia, and cystic fibrosis. Early detection of these variations allow for early disease diagnosis and provide an avenue for treatment before disease symptoms are presented, when a cure is more readily attainable. It has been suggested that specific variations might be a basis for molecular screening assays for the early stages of certain types of cancer. See, e.g., Sidransky, et al., Science, 256: 102-105 (1992). Therefore, in an effort to detect whether certain variations have occurred and further ascertain whether a person is at risk for developing a disease associated with these variations, molecular screening assays have been developed. However, current screening methods are difficult to manage, lack specificity and are not efficient. Furthermore, such screening assays are not reliable for detecting variations that are present in low frequency in the early stages of diseases such as cancer.

[0004] Many cancers are curable if detected early in their development. For example, colorectal cancers typically originate in the colonic epithelium, and are not extensively vascularized (and therefore not invasive) during early stages of development. The transition to a highly-vascularized, invasive and ultimately metastatic cancer commonly takes ten years or longer. If the presence of cancer is detected prior to extensive metastasis, surgical removal typically is an effective cure. However, colorectal cancer is often detected only upon manifestation of clinical symptoms, such as pain and black tarry stool or the presence of blood in stool. Generally, such symptoms are present only when the disease is well established, and often after metastasis has occurred. Early detection of colorectal cancer therefore is important in order to significantly reduce its morbidity.

[0005] Invasive diagnostic methods, such as endoscopic examination, allow direct visual identification, removal, and biopsy of potentially-cancerous tissue. However, endoscopy is expensive, uncomfortable, inherently risky, and not a practical tool for early diagnosis.

[0006] Established non-invasive screening methods involve assaying stool samples for the presence of fecal occult blood or for elevated levels of carcinoembryonic antigen, both of which are suggestive of the presence of colorectal cancer. Additionally, recent developments in molecular biology provide methods of great potential for detecting the presence of a range of DNA variations indicative of colorectal cancer. The presence of such variations can be detected in DNA found in stool samples during various stages of colorectal cancer. However, stool comprises cells and cellular debris from the patient, from microorganisms, and from food, resulting in a heterogeneous population of DNA. This makes detection of small, specific subpopulations difficult to detect reliably.

[0007] Attempts have been made to identify and use nucleic acid events that are indicative of cancer and other diseases. However, even when such events are identified, using them to screen patient samples, especially heterogeneous samples, has proven unsuccessful either due to an inability to obtain sufficient sample material, or due to the low sensitivity that results from measuring only a single marker. For example, simply obtaining an adequate amount of human DNA from one type of heterogeneous sample, stool, has proven difficult. See Villa, et al., Gastroenterol., 110: 1346-1353 (1996) (reporting that only 44.7% of all stool specimens, and only 32.6% of stools from healthy individuals produced sufficient DNA for mutation analysis). Other reports in which adequate DNA has been obtained have reported low sensitivity in identifying a patient's disease status based upon a single cancer-associated mutation. See Eguchi, et al., Cancer, 77: 1707-1710 (1996) (using a p53 mutation as a marker for cancer).

[0008] Increased knowledge of the molecular basis for disease has lead to a proliferation of screening assays capable of detecting disease-associated nucleic acid variations. One such method identifies a genomic region thought to be associated with a disease and compares the wild-type sequence in that region with the sequence in a patient sample. Differences in the sequences constitute a positive screen. See e.g., Engelke, et al., Proc. Natl. Acad. Sci., 85: 544-548 (1988). However, such methods are time-consuming, costly, and do not have sufficient sensitivity to identify the variation of interest in a heterogeneous sample containing a large amount of non-variant nucleic acid. Thus, sequencing is not practical for large-scale screening assays.

[0009] Variations have also been detected by differential hybridization techniques using allele-specific oligonucleotide probes. Saiki et al., Proc. Natl. Acad. Sci., 86: 6230-6234 (1989). Variations are identified on the basis of the higher thermal stability of the perfectly-matched probes as compared to mismatched probes. Disadvantages of this approach for variation analysis include: (1) the requirement for optimization of hybridization for each probe, (2) the nature of the mismatch and the local sequence impose limitations on the degree of discrimination of the probes, and (3) the difficulty in detecting rare variant nucleic acid molecules in heterogeneous populations of nucleic acid. In practice, tests based only on parameters of nucleic acid hybridization function poorly when the sequence complexity of the test sample is high (e.g., in a heterogeneous biological sample). This is partly due to the small thermodynamic differences in hybrid stability generated by single nucleotide changes. In addition, such methods also lack the sensitivity required to detect a small amount of variant nucleic acid in a heterogeneous sample.

[0010] A number of detection methods have been developed which are based on template-dependent primer extension. These methods involve hybridizing primers to template nucleic acids and extending the primers using a polymerase. Those methods can be placed into one of two categories: (1) methods using primers which span the region to be interrogated for the variation, and (2) methods using primers which hybridize upstream of the region to be interrogated for the variation. Typically, the primer extension reaction results in an extended product that can indicate the presence of a variant.

[0011] Strategies based on primer extension require considerable optimization to ensure that only the perfectly annealed oligonucleotide functions as a primer for the extension reaction. The advantage conferred by the high fidelity of the polymerases can be compromised by the tolerance of nucleotide mismatches in the hybridization of the primer to the template. Any “false” priming will be difficult to distinguish from a true positive signal. The reaction conditions of a primer extension reaction can be optimized to reduce “false” priming due to a mismatched oligonucleotide. However, optimization is labor intensive and expensive, and often results in lower sensitivity due to a reduced yield of extended primer. Also, current primer extension reactions do not reproducibly detect small amounts of variant nucleic acid in biological samples. For this reason, there is a need in the art for additional non-invasive methods for early diagnosis of cancer that will detect early characteristics indicative of the presence of cancer.

SUMMARY OF THE INVENTION

[0012] The invention is useful to detect nucleic acid variants or mutations that are present at low frequency in a biological sample. The invention provides methods, compositions, and kits that are useful to detect rare variants or mutations that may otherwise by undetectable in a primer extension assay. According to the invention, a first sequence variant at a predetermined position or target site in a target nucleic acid is detected by performing a primer extension reaction under conditions that prevent misincorporation of a nucleotide that is complementary to the first sequence variant if the target nucleic acid does not contain the first sequence variant at the target site. Accordingly, the specificity of a primer extension reaction is increased by reducing the amount of signal due to misincorporation of a nucleotide complementary to a sequence variant of interest. Typically, the sequence variant of interest is a rare mutation in a heterogeneous biological patient sample such as stool. However, the sequence variant of interest may also be a rare genotype or polymorphism that is present in a heterogeneous sample such as a sample containing a population of viruses or microorganisms or a sample comprised of pooled patient samples. Typically, the nucleotide complementary to the variant of interest is labeled. The invention reduces the amount of background noise due to misincorporation of the label. This allows small amounts of a variant nucleic acid to be detected in a heterogeneous biological sample. The invention also reduces the likelihood of a false positive detection of a variant that is not present in the biological sample. Methods of the invention can also be used to detect the presence of any one of two or three variants at a target position in a target nucleic acid. In one embodiment, the invention includes obtaining a heterogeneous biological sample suspected to contain one or more variant nucleic acids at low frequency. The invention also includes detecting one or more variant target nucleic acids that are present at less than 50%, preferably less than 20%, more preferably less than 10%, more preferably less than 1%, more preferably less than 0.5%, and even more preferably less than 0.1% of the amount of unaltered target nucleic acid in a heterogeneous nucleic acid sample.

[0013] In one aspect, a primer extension reaction of the invention prevents misincorporation of a nucleotide complementary to a first variant by including a blocking nucleotide that is complementary to a second variant at the target site. In a typical biological sample of interest, the abundance of nucleic acids containing the first variant is low relative to that of nucleic acids containing the second variant. Accordingly, the specificity of the extension reaction on target nucleic acids containing the first variant is increased by blocking misincorporation on target nucleic acids containing the second variant. The blocking nucleotide is preferably a terminator nucleotide. However, useful blocking may also be obtained using a nucleotide that is extended inefficiently. In some embodiments, useful blocking may also be obtained using a nucleotide that is extended. However, the blocking nucleotide is preferably different from the nucleotide that is complementary to the first variant. The blocking nucleotide is preferably unlabeled or differentially labeled to reduce background noise in the extension reaction. Typically, the first variant is a mutant or polymorphism that is rare relative to the second variant. Accordingly, the first variant can be referred to as an altered nucleotide. The second variant can be referred to as a wild-type nucleotide, a normal nucleotide, or an unaltered nucleotide. Methods of the invention can be used to detect the presence of one or more of several variant nucleotides at a target site in a heterogeneous sample containing an abundant amount of unaltered target nucleic acids. In some embodiments, several labeled nucleotides can be included in a single reaction in order to detect the presence of any one of several mutations that are complementary to the labeled nucleotides. In other embodiments, several different primers are extended in a single reaction using a single labeled nucleotide that is complementary to a mutation adjacent to any one of the primers. This allows several mutations at different genetic loci to be assayed for in one single multiplexed reaction (provided that each of the mutations is due to the presence of the same mutant nucleotide). Under some circumstances, several different primers and several different labeled terminators may be used in a single reaction if the presence of one or two unlabeled blocking nucleotides blocks extension on the unaltered template nucleic acids without blocking extension on a mutant template nucleic acid that is being assayed for. In one embodiment, a screen to detect a mutation indicative of cancer in a patient includes primer extension reactions designed to detect more than one mutation. Preferably, between 2 and 40 mutations are screened for. More preferably, about 20 mutations are screened for. Even more preferably, 21 mutations are screened for. In addition, a deletion at the BAT-26 locus may also be screened for. In particularly preferred embodiments, any two or more of the primers in the Examples are used to screen for the presence of two or more mutations in a patient sample. According to the invention, the detection of any one of the mutations being screened for is indicative of the presence of disease in the patient.

[0014] In another aspect, the invention increases the specificity of a detection assay by providing a second polymerase in the extension reaction in addition to the blocking nucleotide. Preferably, the second polymerase preferentially incorporates the blocking nucleotide and the first polymerase preferentially incorporates the nucleotide that is complementary to the first variant at the target site.

[0015] In another aspect, the invention provides an internal control to normalize the signal obtained in a primer extension reaction. The internal control is preferably a primer extension reaction that incorporates a control nucleotide that is different from either the first or second nucleotides. The amount of control nucleotide that is incorporated can be used to normalize the observed incorporation of first nucleotide when it is compared to a reference amount indicative of the presence of the first variant in the sample.

[0016] Methods of the invention can be used to detect any variant in a biological sample. However, methods of the invention are particularly useful if the variant is a rare variant that is present in less than 20%, less than 10%, and even less than 1% of the target nucleic acids in a sample. Methods of the invention can be used to detect the presence of rare variants that may otherwise be undetectable due to background signal in a primer extension assay. These and other advantages and aspects of the invention will be understood upon consideration of the following detailed description thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

[0017]FIG. 1 shows six charts that illustrate the results of four different reaction conditions tested using an internal control sequence.

[0018]FIG. 2 shows four charts that illustrate use of the same labeled terminator for the internal control and the sample sequence.

DETAILED DESCRIPTION OF THE INVENTION

[0019] The invention provides methods and compositions for increasing the sensitivity of primer extension assays for detecting nucleic acid mutations or variations in biological samples.

[0020] The invention provides methods for reducing misincorporation of one or more incorrect nucleotides during a primer extension reaction. In general, misincorporation of a mutant or variant nucleotide on a wild-type or unaltered template nucleic acid is reduced by performing a primer extension reaction under conditions that promote incorporation of a correct nucleotide (i.e. wild-type or unaltered) in a primer extension reaction at a target site in the absence of a mutation on the template. Preferably, the incorporation of the correct nucleotide blocks the extension reaction and prevents misincorporation of a mutant or variant nucleotide at that position. According to the invention, a primer extension reaction typically fails to detect a small amount of mutant or variant nucleic acid in a heterogeneous test sample due to nucleotide misincorporation during the extension reaction. For example, nucleotide misincorporation on a wild-type template can result in a background level of incorrectly incorporated mutant nucleotide that conceals a small amount of mutant nucleotide that is correctly incorporated on a small amount of mutant template that may be present in a heterogeneous sample. According to the invention, a significant source of misincorporation results from a correctly hybridized primer being extended with an incorrect nucleotide (i.e. a nucleotide that is not complementary to the template at the position where it is incorporated into the primer extension product). In certain aspects, methods of the invention reduce misincorporation by reducing the number of sites of misincorporation. In further aspects, methods of the invention reduce misincorporation of variant-specific nucleotides and provide highly specific assays for detecting rare variant or mutant nucleic acids in heterogeneous biological samples. Methods of the invention can detect a variant or mutant nucleic acid that represents about 1%, or less, of the target nucleic acid in a heterogeneous nucleic acid sample. The invention is also useful to detect a variant or mutant nucleic acid that represents about 10%, or less; or about 20%, or less of the target nucleic acid in a heterogeneous nucleic acid sample.

[0021] Accordingly, the invention provides primer extension methods and kits that are useful for detecting the presence of nucleic acid variations such as insertions, deletions and/or point mutations in heterogeneous biological samples. In one embodiment, methods of the invention are useful to detect variations at loci that are associated with a disease such as cancer. Also, the invention in generally useful to detect variations at loci having a known wild-type nucleic acid.

[0022] In general, primer extension methods of the invention comprise identifying a target nucleic acid region suspected of containing a variation, and interrogating the target region using a primer extension reaction. A primer is hybridized to a nucleic acid, preferably a single stranded nucleic acid, in the presence of one or more nucleotides and polymerases, and the primer is extended via the incorporation of one or more nucleotides creating a primer extension product. In one aspect, methods of the invention comprise assays for the analysis of a genomic region suspected to be indicative of disease. In general, methods of the invention comprise annealing a primer near a region in which a variation is suspected to occur, and extending the primer in a template-dependent reaction. Also, in one embodiment, methods of the invention include terminating the extension product at a known end-point. In certain embodiments, the extended primer is labeled downstream of a region suspected to be deleted. In certain embodiments, methods of the invention include providing a terminator nucleotide to block the extension on a wild-type or unaltered template. In some embodiments, an extension nucleotide can be used to block or minimize nucleotide misincorporation on a wild-type or unaltered template. Additionally, more than one type of blocking nucleotide may be used. Preferably, the one or more blocking nucleotides are unlabeled to reduce signal noise from abundant unaltered nucleic acid in a heterogeneous nucleic acid sample. According to the invention, a terminator nucleotide is a nucleotide that can be incorporated into a primer extension product, but that cannot be extended further by a polymerase such as DNA polymerase or other similar enzyme. Useful terminator nucleotides include dideoxy NTPs (ddNTPs), alkynyl acycloterminators, and non-extendable analogs thereof. According to the invention, extension nucleotides are nucleotides that can be incorporated into a primer extension product, and can be extended further by a polymerase such as a DNA polymerase or other similar enzyme. Preferred extension nucleotides include deoxynucleotides (dNTPs) and extendable analogs thereof.

[0023] In certain embodiments, the extension reaction is terminated at a site beyond the target region. In other embodiments, the extension product is analyzed, and the product is used as an indicator of the presence or absence of a mutation or variation in the target nucleic acid region. Also, the presence of certain extension products may be indicative of the presence of a deletion in the target region. Conversely, the presence of certain extension products may be generally indicative of the presence of an insertion in the target region. However, the presence of extension product can also be an indicator of a point mutation in the target region, as exemplified in greater detail in the examples that follow.

[0024] 1. Providing A Blocking Nucleotide to Increase Sensitivity of Primer Extension Assays

[0025] Certain aspects of the invention are useful for identifying a variation at a pre-determined position in a nucleic acid. In one embodiment, methods of the invention include providing a target nucleic acid; contacting the target nucleic acid sequence with a nucleic acid primer substantially complementary to a region of the target nucleic acid sequence to form a nucleic acid complex; extending the nucleic acid primer in the presence of a wild-type nucleotide complementary to a wild-type nucleotide and a variant nucleotide complementary to variant nucleotide, wherein the wild-type extension nucleotide will be incorporated into an extension product on a wild-type target nucleic acid and the variant extension nucleotide will be incorporated into an extension product on a variant target nucleic acid, thereby preventing a wild-type nucleotide from misincorporating opposite a variant base or a variant nucleotide from misincorporating opposite a wild-type base. Preferably, the wild-type nucleotide is unlabeled and the variant nucleotide is labeled. Alternatively, the wild-type extension nucleotide can be labeled with a label that is detectably different than the label of the variant nucleotide. According to a preferred embodiment, the wild-type nucleotide is a terminator nucleotide. Alternatively, or in addition, the variant nucleotide can be a terminator nucleotide. In one embodiment, wild-type and variant nucleotides are the only nucleotides added to the primer extension reaction. However the primer extension reactions can also include other variant-specific nucleotides or internal controls.

[0026] Further methods of the invention include providing a target nucleic acid; contacting the target nucleic acid sequence with a nucleic acid primer substantially complementary to the target nucleic acid sequence to form a nucleic acid complex; extending the nucleic acid primer in the presence of an unlabeled extension nucleotide complementary to a variant nucleotide base at a position downstream from the nucleic acid primer in the target nucleic acid sequence to form an unlabeled primer extension product, wherein the extending step is performed in the essential absence of an unlabeled extension nucleotide complementary to a wild-type nucleotide base at a position downstream from the nucleic acid primer; and extending the unlabeled primer extension product in the presence of a labeled extension nucleotide complementary to a corresponding wild-type nucleotide downstream from the position of the variation in the target nucleic acid sequence to form a labeled extension product. A terminator nucleotide corresponding to the unaltered nucleotide at the target position is preferably included in the reaction mixture to block the extension of primers hybridized to unaltered target nucleic acid molecules. This prevents misincorporation of variant nucleotides on unaltered templates.

[0027] In another aspect, methods of the invention further include the step of terminating a labeled extension product with a terminator of a nucleic acid primer extension capable of terminating the labeled extension product. In one embodiment, a terminator corresponding to a nucleotide in a corresponding variant and/or wildtype sequence is provided downstream from the labeled extension product.

[0028] In another aspect, the invention provides methods for essentially minimizing or reducing background signal when interrogating a target nucleic acid region suspected of containing a variation. Generally, methods of the invention include the steps of contacting a single stranded target nucleic acid sequence with a nucleic acid primer substantially complementary to said target nucleic acid sequence; providing an extension (or a terminator) nucleotide complementary to a variant nucleic acid sequence; and, providing a terminator, wherein the terminator corresponds to a wild-type nucleotide at a potentially variant site such that extension of the nucleic acid primer hybridized to a wild-type nucleic acid is essentially prevented, thereby blocking extension of the wild-type template and minimizing background when interrogating a target nucleic acid suspected of containing a variation.

[0029] In one embodiment, a region suspected to contain a deletion comprises a poly-nucleotide tract or repeat in which the deletion is suspected to occur, and the sequence immediately downstream of the region is known and does not repeat a nucleotide species present in the polynucleotide tract. Preferably, the polynucleotide tract comprises three, two, or preferably one, species of nucleotide.

[0030] Also, methods of the invention retain the specificity of primer extension assays while increasing their sensitivity by reducing background due to primer extension on a wild-type nucleic acid. Therefore, methods of the invention provide a highly sensitive and highly specific assay for detecting a small amount of variant nucleic acid in a heterogeneous sample of predominantly wild-type nucleic acid. As provided by the examples shown herein, the invention provides for essentially minimizing background by blocking extension of a primer corresponding to wild-type nucleic acid sequences when interrogating a target nucleic acid region suspected of containing a variation. For example, methods of the invention include the steps of contacting a single stranded target nucleic acid sequence with a nucleic acid primer substantially complementary to said target nucleic acid sequence; providing an extension nucleotide complementary to a variant nucleic acid sequence; and, providing a terminator, wherein the terminator corresponds to a wild-type nucleotide at the potentially variant site such that extension of the nucleic acid primer corresponding to a wild-type nucleic acid is essentially prevented, thereby minimizing background when interrogating a target nucleic acid suspected of containing a variation.

[0031] Methods of the invention provide screening assays for the detection of a variation in a region of the genome comprising at least one species of nucleotide, and that is characterized by having a sequence for primer hybridization immediately downstream or upstream, and a sequence immediately downstream or upstream that does not contain a nucleotide present in the region suspected to be deleted. Variations can include, for example, nucleic acid insertions, deletions, and point mutations. In a preferred embodiment, methods of the invention comprise selecting a nucleic acid having a known wild-type sequence and having a region where a variation is suspected; hybridizing an oligonucleotide primer, or pair of oligonucleotide primers, immediately downstream or upstream of the target region; extending the primer by using a polymerase in the presence of the nucleotide bases that are complementary to the nucleotide bases of the target region, thereby to form a primer extension product; and, further extending the primer extension product in the presence of a labeled nucleotide that is complementary to a nucleotide base downstream from the target region, but not complementary to a nucleotide base within the target region. Further embodiments may include the step of determining the size of the extension product compared to a standard (e.g., a wild-type product or a molecular weight standard).

[0032] In a preferred embodiment, the primer extension product is terminated by incorporating a terminator nucleotide that is complementary to a nucleotide downstream from the target region in a wild type nucleic acid. In certain embodiments, the terminator may not be complementary to any of the nucleotides of the target region. However, in certain embodiments, the terminator may be complementary to a nucleotide of the target region. In an embodiment of the invention, the terminator may correspond to a known variation in the variant nucleic acid. In another embodiment, the terminator may correspond to a known nucleotide in the wild-type sequence. In an alternative embodiment, more than one nucleotide base is incorporated into the extension product prior to incorporation of the terminator nucleotide. In a highly preferred embodiment, an unlabeled nucleotide is incorporated into the extension product prior to the incorporation of the labeled nucleotide. Also, in a highly preferred embodiment, first, the unlabeled nucleotide is incorporated into the nucleic acid primer forming an extension product, and thereafter the labeled nucleotide is incorporated into the extension product. Furthermore, in another highly preferred embodiment, a terminator is introduced to remove background. In one embodiment, nucleotides incorporated during extension through the region suspected of containing a deletion are unlabeled.

[0033] In a preferred embodiment, methods of the invention comprise detecting a nucleic acid variation in a biological sample, such as stool, urine, semen, blood, sputum, cerebrospinal fluid, pus, or aspirate, that contains a heterogeneous mixture of nucleic acid having a deletion in the target region and wild type nucleic acid. Such a deletion in the target region may be present in only about 1-5% of the nucleic acid molecules having the target region. To increase the sensitivity of the assay, the sample may comprise a polymerase chain reaction product. Method of the invention are particularly useful in analyzing a deletion in the target region that is indicative of the presence of cancerous or precancerous tissue in such a biological sample, including colorectal cancer or precancer detection in stool.

[0034] In another embodiment, methods of the invention comprise detecting a mutation, such as, for example, a deletion in a sample by selecting a nucleic acid with a known wild-type sequence and having a target region suspected of containing a deletion, wherein the target region contains at least one or at most three different types of nucleotide bases selected from the group consisting of dGTP, dATP, dTTP, and dCTP; hybridizing an oligonucleotide primer to a region adjacent to the target region, in a nucleic acid sample; contacting the hybridized oligonucleotide primer with an extension reaction mixture comprising: i) nucleotides which are complementary to the nucleotides in the target region, ii) a labeled nucleotide which is complementary to a nucleotide found upstream or downstream from the target region, and iii) a terminator nucleotide which is complementary to a nucleotide found upstream or downstream from the target region, but which is not complementary to any nucleotide found in the target region; and extending the hybridized oligonucleotide primer to generate a labeled extension product.

[0035] 2. Using Two Different DNA Polymerases to Reduce Misincorporation of Nucleic Acids

[0036] Certain aspects of invention relate to primer extension methods using two or more different polymerases for detecting and identifying variant nucleic acids within a heterogeneous population of nucleic acids. Methods of the invention reduce misincorporation of variant-specific nucleotides in primer extension assays by providing a specific polymerase that preferentially incorporates an unaltered nucleotide in a primer extension reaction in the absence of a sequence variation in the template nucleic acid. According to the invention, a significant source of misincorporation results from a correctly hybridized primer being extended with an incorrect nucleotide (i.e. a nucleotide that is not complementary to the template at the position where it is incorporated into the primer extension product). The invention provides methods for reducing misincorporation by reducing the number of sites of potential misincorporation.

[0037] In general, misincorporation is reduced by performing a primer extension reaction in the presence of at least two different nucleotides, one of which is expected to be incorporated into the primer extension product in the absence of a first nucleotide sequence on the template, and the other of which is expected to be incorporated into the primer extension product if the template contains a second nucleotide sequence instead of the first nucleotide sequence. In addition, the primer extension reaction is performed in the presence of at least two polymerases, each of which preferentially incorporates one of the two nucleotides. The polymerase that preferentially incorporates a first nucleotide reduces the possibility of misincorporation of a second nucleotide in primer extension reactions where the template contains a first nucleotide sequence. Preferably, one of the nucleotides is labeled and the other one is not labeled. The labeled nucleotide is preferably the one that is incorporated in the primer extension product when the template contains a sequence to be detected. In alternative embodiments, both first and second nucleotide may be labeled if they are differentially labeled such that the label on one of the nucleotides is detectably different from the label on the other nucleotide.

[0038] According to the invention, reducing the rate of misincorporation increases the sensitivity of primer extension assays and allows for the detection of rare nucleic acid variations in heterogeneous biological samples. Misincorporation of a nucleotide corresponding to a mutation in a primer extension reaction can lead to a false positive detection of the presence of the mutation in a nucleic acid sample. In a typical primer extension reaction on a biological sample that contains mostly wild-type nucleic acids, misincorporation results in a background level of false positive signal that is high enough to obscure a true positive signal generated from a relatively small amount of mutant nucleic acids. Therefore, by reducing the amount of misincorporation, aspects of the invention provide highly sensitive and highly specific assays for detecting rare variant and/or mutant nucleic acid in heterogeneous biological samples.

[0039] Aspects of the invention involve using two different polymerases; a first polymerase that preferentially incorporates a first nucleotide and a second polymerase that preferentially incorporates a second nucleotide. In one aspect, the first nucleotide can be a variant nucleotide and the second nucleotide can be an unaltered or wild-type nucleotide. In further aspects of the invention, the first nucleotide can be a polymorphism or other alteration, such as a deletion, insertion or point mutation. Having both polymerases present when performing a primer extension reaction reduces the risk of a variant nucleotide binding to a wild-type base, causing a false positive result when screening for nucleic acid variations. Additionally, this method reduces the risk of a wild-type nucleotide binding to a variant base, causing a false negative result when screening for nucleic acid variations.

[0040] Primer extension methods of the invention generally comprise identifying a target nucleic acid region suspected of containing a variation, and interrogating the target region using a primer extension reaction. A primer is hybridized to a single stranded nucleic acid in the presence of extension nucleotides and polymerases, and the primer is extended through the target region creating a primer extension product.

[0041] In one embodiment, a method of the invention includes the steps of contacting a single stranded target nucleic acid with a nucleic acid primer substantially complementary to said target nucleic acid sequence; providing an extension nucleotide complementary to a variant nucleic acid sequence; and providing a terminator, wherein the terminator corresponds to a wild-type nucleotide at the potentially altered site such that extension of the nucleic acid primer corresponding to a wild-type nucleic acid is prevented. In an alternate embodiment, the extension nucleotide is complementary to a wild-type nucleic acid sequence and the terminator corresponds to a variant nucleotide at the potentially altered site such that extension of the nucleic acid primer corresponding to a variant nucleic acid is prevented.

[0042] In further embodiments, a primer is designed to bind and begin hybridization at the base suspected of containing a variant and will only bind and extend if a variant base is present. Alternatively, the primer can be designed to bind and begin hybridization at the base suspected of containing a variant and will only bind and extend if a wild-type base is present. In other embodiments, the primer is designed to bind and begin hybridization at a base upstream from the target region suspected of containing a variant base, and will only extend through the target region if a variant base is present in the target region. Alternatively, the primer can be designed to bind and begin hybridization at a base upstream from the target region suspected of containing a variant base, and will only extend through the target region if no variant base is present.

[0043] In another embodiment, the method involves the steps of contacting a single stranded target nucleic acid sequence with a nucleic acid primer substantially complementary to the target nucleic acid sequence, and providing a labeled extension nucleotide complementary to a variant nucleic acid sequence such that the presence of a labeled extension product indicates the presence of a variant in the target nucleic acid region. Alternatively, the method involves the steps of contacting a single stranded target nucleic acid sequence with a nucleic acid primer substantially complementary to the said target nucleic acid sequence, and providing a labeled extension nucleotide complementary to a wild-type nucleic acid sequence such that the presence of a labeled extension product indicates the lack of a variant in the target nucleic acid region. In a further embodiment, the extension nucleotide complementary to an altered nucleic acid sequence is labeled with a first label and the extension nucleotide complementary to a wild-type nucleic acid sequence is labeled with a second label. The first label is different than the second label and can be visually differentiated from the second label.

[0044] The extension product can be analyzed and used to indicate the presence or absence of a variant in the target region. The presence of certain extension products can be an indicator of the presence of an insertion, deletion, point-mutation or other alteration within the target region. In one embodiment, methods of the invention are useful in detecting nucleic acid methylation.

[0045] Polymerases with Preferential Incorporation:

[0046] Preferential incorporation of one terminator over another can be measured by running parallel reactions which differ only in the type and concentration of each terminator. The relative incorporation efficiency of two different terminators can be reflected in the concentrations of terminators in the two reactions. For example, a first reaction that contains 10-fold more of a first terminator than a second reaction containing a second terminator demonstrates that insertion of the first terminator is 10-fold less efficient than that of the second terminator. These concentration levels can be measured by various methods, including, for example, performing titration assays, running the samples on DNA sequencing gel and visualizing the extent of terminator incorporation by autoradiography. If the incorporation of a first terminator over a second terminator is a 10-fold or greater difference, a determination can be made that the first terminator was preferentially incorporated. Preferably, a first polymerase incorporates a first polymerase with between a 2 fold and a 100 fold preference. More preferably, the ratio of incorporation is between 5 fold and 50 fold. Even more preferably, the ratio is about 10 fold. However, ratios less than 2 fold and greater than 100 fold can also be useful. The preference of the first polymerase for the first nucleotide relative to the second nucleotide can also be measured as a percentage increase in incorporation in an assay. Preferably, a first polymerase has between about a 5% and a 100% preference for a first type of nucleotide relative to a second type of nucleotide. More preferably, the preference is between 25% and 75%. Examples of DNA polymerases that preferentially incorporate dideoxy terminators include Taq polymerase and Thermo Sequenase. (Gardner, A., (2002) “Acyclic and dideoxy terminator preferences denote divergent sugar recognition by archaeon and Taq DNA polymerases”, Nucleic Acids Research, Vol. 30, No.2 pp. 605-613.) Examples of DNA polymerases that preferentially incorporate acyclic terminators include Vent, Vent A488L, Deep Vent, 9°N and Pfu . In one embodiment of the invention, preferential incorporation can also be achieved by using dye-labeled terminators. Examples of DNA polymerases that preferentially incorporate dye-labeled terminators include Vent DNA polymerase, which preferentially incorporates dye-labeled dCTP analogs over unmodified dCTPs, and dye-acyCTPs over dye-ddCTPs, and Vent, Deep Vent, Pfu and 9°N polymerases, which preferentially incorporate dye-acyNTPs over dye-ddNTPs.

[0047] Applications

[0048] Methods of the invention are useful in the context of detecting a rare mutation in a heterogeneous biological sample (e.g. a sporadic mutation in a heterogeneous patient sample); detecting rare genotypes in genotyping reactions (e.g. viral genotyping reactions); detecting mutant or variant sequences in pooled samples (e.g. detecting polymorphisms or inherited sequence variations in pooled patient samples).

[0049] 3. General Considerations

[0050] Methods of the invention also provide screening assays for the detection of a variation in a region of the genome comprising at least one species of nucleotide, and that is characterized by having a sequence for primer hybridization immediately downstream or upstream, and a sequence immediately downstream or upstream that does not contain a nucleotide present in the region suspected to contain a variant. In one embodiment, methods of the invention comprise selecting a nucleic acid having a known wild-type sequence and having a region where a variant is suspected; hybridizing an oligonucleotide primer, or pair of oligonucleotide primers, immediately downstream or upstream of the target region; extending the primer by using a polymerase in the presence of the nucleotide bases that are complementary to the nucleotide bases of the target region, thereby to form a primer extension product; and, further extending the primer extension product in the presence of a labeled nucleotide that is complementary to a nucleotide base downstream from the target region, but not complementary to a nucleotide base within the target region. Further embodiments may include the step of determining the size of the extension product compared to standard (e.g., a wild-type product or a molecular weight standard). In some embodiments, the target nucleic acid is denatured. In some embodiments, the primer is exactly complementary to the target region. In alternative embodiments, the primer may contain at least one or two mismatches in order to reduce the generation of background signal observed after the extension reaction. The nucleic acid primer is preferably a DNA primer or analog thereof. However, the primer may also be a PNA, RNA, or analog thereof.

[0051] In one embodiment, methods of the invention can be performed in parallel, whereby the primer extension reaction is run in parallel with more than one biological sample. Such reactions can be run by using a multi-well plate in which one biological sample is placed in each well and each primer extension reaction is performed separately within each well. Each well may contain the same or different biological samples than each of the other wells.

[0052] In another embodiment, methods of the invention comprise extending the primer extension product in the presence of labeled and unlabeled nucleotides, the nucleotides being of the same type (e.g., A, T, C, or G) and being complementary to one or more nucleotides downstream from the target region but not complementary to a nucleotide within the target region. In one embodiment the ratio of the labeled nucleotide to unlabeled nucleotide is 1:1. Methods of the invention may also include incorporating more than one monomer of the labeled nucleotide or unlabeled nucleotide into the extension product.

[0053] The invention provides for terminators that comprise nucleotides, nucleotide analogs, dideoxynucleotides, or other known molecules appropriate for the invention. In certain embodiments, the invention provides for the use of terminators comprising dideoxynucleotide triphosphates (ddNTP), such as, for example, dideoxyadenosine triphosphates (ddATP), dideoxycytosine triphosphates (ddCTP), dideoxyguanosine triphosphates (ddGTP), dideoxythymidine triphosphates (ddTTP), or dideoxyuridine triphosphates (ddUTP). Other embodiments of the invention provides for the use of other terminators or primers commonly known to those skilled in the art.

[0054] In certain embodiments, the terminators may not be detectably labeled. In other embodiments, however, the terminators may be detectably labeled. Terminators may comprise labels such as a fluorophore, a chromophore, an isotopticaly labeled moiety, an enzymatic label, or a radioactive label. Other embodiments provide for other labels commonly known to those skilled in the art. Alternate embodiments include a plurality of labels, such as the use of more than one fluorophores to differentiate the detection of particular nucleotides. In another embodiment, the first nucleotide is labeled in similar manner, and the second nucleotide is unlabeled. Furthermore, in certain aspects, extension nucleotides may be detectably labeled in a similar manner.

[0055] Methods of the invention are also useful to detect small amounts of hypermethylated template in a heterogeneous biological sample. Hypermethylation can be indicative of the presence of a disease such as cancer. For example, hypermethylation of any one of the APC, hMLH, P16, MGMT, P14, HLTF, MINT31, and MINT2 loci, particularly in the 5′ region of the gene, can be indicative of cancer. Particularly useful primers for detecting hypermethylation at a genetic locus are primers that hybridize to a template nucleic acid upstream or immediately adjacent to a position (a CpG) suspected to be methylated if the target genetic locus is hypermethylated. According to the invention, a target nucleic acid sample is treated with bisulfite to modify the umnethylated CpG dinucleotides. The bisulfite reaction modifies the C to a U in an umnethylated CpG dinucleotide. Accordingly, bisulfite modification of a heterogeneous nucleic acid sample containing a small amount of methylated CpG at a predetermined position produces a small amount of target nucleic acid a C and a large amount of target nucleic acid with a U at the predetermined position. The invention allows detection of the small amount of C by including A nucleotide (along with G nucleotide) in the extension reaction to prevent misincorporation of a G nucleotide on a template containing a U at the predetermined position. As discussed above, the A is preferably unlabeled and is preferably a terminator nucleotide. A second polymerase may also be used in this assay as discussed above.

[0056] In further embodiments, the invention includes the step of running the primer extension reaction using an internal control nucleic acid having a different nucleotide sequence than the wild-type and the variant. The control nucleotide is complementary to a corresponding control template nucleotide sequence and is not incorporated into the extension product of either a normal or variant primer extension reaction. The control extension nucleotide is preferably labeled. In one embodiment, an internal control nucleic acid can be added to a reference primer extension reaction containing 99 % known wild-type template nucleic acid and 1 % known variant template nucleic acid in order to generate 1) a labeled primer extension product in which a labeled variant-specific nucleotide has been incorporated and 2) a labeled primer extension product in which a labeled control nucleotide is incorporated. The extension products can provide a reference signal to determine whether the amount of signal produced by a suspected variant in a biological sample reflects a true positive or a true negative result, or whether the variant signal is the result of other reaction conditions. Accordingly, the control signal is used to determine whether the signal from the labeled variant-specific nucleotide is indicative of the presence of a rare variant in a biological sample. The signal strength generated by a primer extension reaction designed to detect a mutant or variant can be compared to the signal strength of the internal control to determine the relative strength of the mutant or variant-specific signal. According to the invention, different percentage concentrations of internal control template can be used to generate a reference level for determining whether a rare variant is present.

[0057] According to the invention, the internal control nucleic acid can be included in each primer extension reaction performed using a biological sample of interest so that the signal corresponding to the control can be compared to any signal corresponding to a possible rare variant, therefore providing a reference signal for use in determining whether a rare variant is actually present. A control nucleic acid can be used in conjunction with two different polymerases and does not interfere with the preferential incorporation of a wild-type or variant nucleotide. In a preferred embodiment, the control nucleotide is a terminator nucleotide. In a preferred embodiment, the same lot of labeled nucleotides for the internal control and the same lot of labeled nucleotides for the variant are used throughout each primer extension reaction. This prevents signal fluctuations among different dye lots, which could otherwise be interpreted as false positives or false negatives.

[0058] Methods of the invention are especially useful to detect indicia of cancer or precancer in a heterogeneous sample. Stool is a good example of a heterogeneous sample in which methods of the invention are useful. A typical stool sample contains patient nucleic acids, but also contains heterologous nucleic acids, proteins, and other cellular debris consistent with the lytic function of the various nucleases, proteinases and the like found in the colon. Under normal circumstances, stool solidifies as it proceeds from the proximal colon to the distal colon. As the solidifying stool passes through the colon, colonic epithelial cells are sloughed onto the stool. If a patient has a developing tumor or adenoma, cells from the tumor or adenoma will also be sloughed onto stool. Those cells, and/or their debris, will contain molecular indicia of disease (e.g., variations or loss of heterozygosity). In the early stages of development, nucleic acid indicative of an adenoma or tumor comprise only about 1% of the nucleic acid in a voided stool. If left untreated, proportionately more disease-related nucleic acids are found in stool. Methods of the invention are useful for detecting early-stage lesions in heterogeneous samples such as stool. Methods of the invention result in a high degree of sensitivity and specificity for the detection of early-stage disease. Methods of the invention are especially useful in detecting, for example, adenomas in the colon. Adenomas are non-metastatic lesions that frequently have the potential for metastasis. If all adenomas in a patient are detected and removed, the probability of complete cure is virtually certain.

[0059] Mutations, such as deletions in the various loci, such as, for example, BAT26, APC, DCC, p53, and Kras have been associated with cancer, such as, for example colorectal cancer. Thus, in a highly-preferred embodiment, the region in which a deletion is suspected to occur is in the BAT26, APC, DCC, p53 and/or Kras locus. Use of methods of the invention on certain loci identifies the characteristic variations (deletions, insertions, point mutations or other alterations) by producing an extension product in affected nucleic acids that is different than the expected wild-type extension product.

[0060] Also, in another aspect, methods of the invention provide methods for identifying indicia of cancer in tissue or body fluid samples by interrogating non-apoptotic DNA in those samples. The invention also provides methods for identifying indicia of cancer or precancer in samples containing exfoliated epithelial cells. It has now been recognized that DNA obtained from exfoliated normal (non-cancerous) cells is different than DNA obtained from exfoliated cancer or precancer cells. Normal exfoliated cells typically have undergone apoptosis, and thus produce cells or cellular debris (depending upon the stage of apoptosis) comprising DNA that has been substantially degraded. Exfoliated cancer or precancer cells typically have not undergone apoptosis, and such cells or their debris, while producing some very small fragments as a result of degradation in the sample, typically also contain a higher proportion of large DNA fragments (compared to those observed in cells or debris from exfoliated normal cells). According to the invention, the difference in DNA integrity between normal and abnormal cells is not only a marker for the presence of cancer or precancer in a sample comprising exfoliated cells, but can also be used to preferentially interrogate mutant DNA by interrogating high integrity nucleic acid.

[0061] Stool is a good sample for exemplification of methods of the invention. The colonic epithelium undergoes a continual process of exfoliation. Normal epithelial cells undergo apoptosis, and are sloughed into the lumen of the colon, and onto forming stool. Cells from polyps and tumors are also sloughed onto forming stool. However, cells from polyps or tumors are typically not apoptotic. Methods of the invention take advantage of the different characteristics between apoptotic and non-apoptotic cells in order to screen patient samples for indicia of cancer or precancer.

[0062] As noted above, non-cancerous (normal) cells undergo apoptosis at regular intervals, or in response to irreparable cell damage. As a result of apoptosis, DNA from normal cells is cleaved into small fragments having about 200 or fewer base pairs, and typically 180 base pairs or less. In contrast, DNA obtained from cancer or precancer cells is much larger than the typical apoptotic fragments. Thus, the presence of large DNA fragments in a sample (e.g., of sloughed colonic epithelium) indicates that there are or were cells in the sample (or the specimen from which it was obtained) that have avoided apoptosis, and its coincidental degradation of DNA. The presence of large DNA fragments represents a positive screen for cancer or precancer.

[0063] Accordingly, methods of the invention comprise detecting the presence in a biological sample of species-specific nucleic acids indicative of cancer or precancer. Samples comprising such nucleic acids are identified as having indicia of cancer or precancer. In preferred methods, patients presenting samples having a high proportion of non-apoptotic nucleic acids as determined by methods of the invention are further evaluated for the presence of a tumor, adenoma, or other cancerous or precancerous lesion.

[0064] In one aspect, methods of the invention comprise interrogating in a biological sample one or more DNA fragment(s) of a length that would not be substantially present in noncancerous cells or cellular debris. In a preferred embodiment, such fragments are larger than a typical apoptotic spindle fragment, or larger than about 170 base pairs. However, also in a preferred embodiment, methods of the invention comprise interrogating DNA fragments that are greater than about 200 base pairs, and preferably greater than about 500 base pairs. There is no upper limit on these fragments, as all that is necessary is that the fragment be larger than an apoptotic fragment. Typically, however, fragments indicative of cancer or precancer cells are between about 200 and about 3500 base pairs, and ideally between about 500 and about 2500 base pairs.

[0065] In the present invention, useful biological samples include any sample from a patient in which a target nucleic acid region is present. These samples can be prepared from any cell, tissue, or body fluid. Biological cell sources include, for example, blood cells, colon cells, buccal cells, cervicovaginal cells, epithelial cells from urine, fetal cells or cells present in tissue obtained by biopsy. Tissues and body fluids include, for example, sputum, pancreatic fluid, bile, lymph, plasma, urine, cerebrospinal fluid, seminal fluid, saliva, breast nipple aspirate, pus, amniotic fluid and stool. Biological samples can also include isolated nucleic acid obtained from any cell, tissue or body fluid of a patient. The nucleic acid can be isolated by any method that is standard in the art and the isolation method will depend on the source of the biological sample.

[0066] In one embodiment, one or more specific regions of the target nucleic acid are amplified using any known methods of amplification, such as polymerase chain reaction (PCR). In certain embodiments, the comparative length and/or molecular weight of the extended primer is determined by gel electrophoresis or mass spectroscopy. In further embodiments, detecting labeled products may be performed by capillary electrophoresis or other methods commonly known to those skilled in the art.

[0067] Aspects of the invention also comprise kits containing all of the appropriate reagents and material for preparing and conducting the primer extension and/or DNA integrity assays described herein.

[0068] Additional aspects of the invention are described in the following sections and illustrated by the following examples.

EXAMPLES Example 1 Variation Detection at Specific Loci

[0069] Experiments were conducted to demonstrate the usefulness of the primer extension invention to detect mutations in the various loci known to be related to colorectal cancer. For example, primer extension protocols were designed using the methods of the invention to detect variants at various loci known to be related to colorectal cancer.

[0070] Choosing the Target Region and the Oligonucleotide Primer

[0071] Preferably, a locus associated with a disease such as cancer is chosen. Most preferably, a locus that is known to frequently exhibit one or more mutations, such as deletions or point mutations is chosen. Preferably, a chosen locus comprises a nucleotide in which a mutation is suspected to occur. Once a locus is chosen, primers are designed or chosen to maximize specificity of binding to a nucleotide sequence adjacent to the region suspected of containing a mutation. Particularly useful primers are described in this and the following examples.

[0072] Sample Preparation and Hybridization

[0073] Methods of the invention are performed on any tissue or body fluid, including biopsy samples, and others having a high concentration of affected (i.e., mutated) cells or cellular debris. However, methods of the invention are particularly useful for detecting variations in heterogeneous biological samples. A preferred sample is stool. For the analysis of stool samples, preferred methods of the invention comprise obtaining at least a cross-section or circumferential portion of a voided stool as taught in U.S. Pat. No. 5,741,650, and co-pending, co-owned U.S. patent application Ser. No. 09/059,718, both of which are incorporated by reference herein. While a cross-sectional or circumferential portion of stool is desirable, methods provided herein are conducted on random samples obtained from voided stool, which include smears or scrapings. Once obtained, the stool specimen is homogenized. A preferable buffer for homogenization is one that contains at least 16 mM ethylenediaminetetraacetic acid (EDTA), as taught in co-pending, co-owned U.S. patent application Ser. No. 60/122,177, incorporated by reference herein. It has been discovered that the use of at least 16 mM EDTA, and preferably 100 mM EDTA greatly improves the yield of nucleic acid from stool. Thus, a preferred buffer for stool homogenization comprises phosphate buffered saline, 20-100 mM NaCl or KCl, at least 16 mM EDTA, and optionally a detergent (such as SDS) and a proteinase (e.g., proteinase K).

[0074] After homogenization, nucleic acid is preferably isolated from the stool sample. Isolation or extraction of nucleic acid is not required in all methods of the invention, as certain detection techniques can be adequately performed in homogenized stool without isolation of nucleic acids. In a preferred embodiment, however, homogenized stool is spun to create a supernatant containing nucleic acids, proteins, lipids, and other cellular debris. The supernatant is treated with a detergent and proteinase to degrade protein, and the nucleic acid is phenol-chloroform extracted. The extracted nucleic acids are then precipitated with alcohol. Other techniques can be used to isolate nucleic acid from the sample. Such techniques include hybrid capture, and amplification directly from the homogenized stool. Nucleic acids can be purified and/or isolated to the extent required by the screening assay to be employed.

[0075] Nucleic acids to be analyzed are chosen based upon known or suspected relationships between specific mutations and cancer or precancer. If desired, sequence-specific hybrid capture is used to isolate specific nucleic acids from the sample. Target nucleic acids may be analyzed by any method of the art. However, target nucleic acids isolated using the capture probes described herein are preferably analyzed using the primer extension assays or DNA integrity methods of the invention. In addition to the detection of the presence of a variation using detection tools such as capillary electrophoresis and other fluorescent detecting methods, other examples of methods for analysis include enumerative analysis of the loss of heterozygosity as taught in U.S. Pat. No. 5,670,325, incorporated by reference herein. Enumerative methods do not require knowledge of the sequence of a variant nucleic acid. Rather such methods determine that there has been an alteration (deletion, substitution, addition, rearrangement, or other mutation) in a wild-type nucleic acid. The investigated loci are chosen based upon the likelihood of an alteration being associated with cancer or precancer. Enumerative methods can be used to compare the number in a sample of a wild-type nucleic acid known not to be altered in cancer or precancer with the number of a wild-type nucleic acid known or suspected to be altered in cancer or precancer. A statistically-significant difference in the two numbers indicates a positive screen. In preferred enumerative methods, a number of molecules containing a first SNP (single nucleotide polymorphism) is compared to a number of molecules containing a second SNP, and the presence of a statistically significant difference is indicative of the presence of diseased, cancerous, or precancerous cells.

[0076] Useful primer sequences for sequence specific capture are shown in Table 1. Table 1 provides information regarding the size, percent G/C and TM information for each capture probe. TABLE 1 Capture Probe Sequences TM % TM (nearest SEQ. Name Sequence 5′-3′ GC ({fraction (2/4)} rule) neighbor) ID NO: CAP-A Gtggagtatttgatagtgtattaaccttatgtgtgac 35% 100 75 1 CAP-B Ttccagcagtgtcacagcaccctagaaccaaatccag 51% 112 89 2 CAP-C/D Cagatagccctggacaaaccatgccaccaagcagaag 54% 114 91 3 CAP-E Tactcccctgccctcaacaagatgttttgccaactgg 51% 112 90 4 DAP-F1 Atttcttccatactactacccatccacctctcatc 43% 100 79 5 CAP-F2 Atgaggccagtgcgccttggggagacctgtggcaagc 65% 122 97 6 CAP-C Gaaaggacaagggtggttgggagtagatggagcctgg 57% 116 90 7 CAP-J1 Ttaagaatttaaaaatcgaagatttctataccactgg 27% 94 77 8 CAP-J2 Acagatagtgaagaaggcttagaaaggagctaaaaga 38% 102 79 9 CAP-L Gaagttcctggattttctgttgctggatggtagttgc 46% 108 86 10 CAP-M Gattctgaagaaccaactttgtccttaactagctctt 38% 102 79 11 CAP-N Ctaagtttgaatccatgctttgctcttcttgattaff 32% 98 80 12 CAP-P Aagaggagctgggtaacactgtagtattcaaatatgg 41% 104 80 13 CAP-Q Gaatgtattatttctgccatgccaacaaagtcatcac 38% 102 83 14 CAP-K1 Tcagaagggagaaacacagtctggattattacagtgc 43% 106 83 15 CAP-K2 Aattatagtttttattttttgagtctttgctaatgcc 24% 92 76 16 CAP-R1 Catgtgctgtgactgcttgtagatggccatggcgcgg 60% 118 96 17 CAP-R2 Gcaactggggtctctgggaggaggggttaagggtggt 62% 120 93 18 CAP-S1 Gaatgtattatttctgccatgccaacaaagtcatcac 38% 102 83 19 CAP-52 Cttctgcttggtggcatggtttgtccagggctatctg 54% 114 91 20 CAP-T1 Agaagtacatctgctaaacatgagtggggtctcctga 46% 108 84 21 CAP-T2 gcagttcagagggtccaggttcttccagatgctgata 51% 112 88 22

[0077] The capture probe sequences are preferably modified with a 5′-biotin. CAP-A is used to capture the sequences at KrasCp2 locus. CAP-B and CAP-C/D are used to capture sequences at the APC locus. CAP-E, CAP-F1, CAP-F2, and CAP-G are used to capture sequences at the p53 locus.

[0078] Primer Extension, Labeling and Termination.

[0079] A hybridized primer is extended through a target region suspected of containing a variation at a target position using known reagents for primer extension, including extension using DNA polymerases. At least one of the extension nucleotides preferably is labeled using a detectable label. Preferably, a labeled nucleotide is added to the extended primer once extension through a target position containing a variation is complete. In a preferred embodiment, the labeled extension reaction is terminated at a predetermined position downstream from the target position. In an embodiment, the labeling and termination steps are performed simultaneously. In a preferred embodiment a labeled nucleotide is incorporated into the extended primer downstream from the target position. Also, in a preferred embodiment, an unlabeled terminator is incorporated into the extended primer downstream from the labeled nucleotide. Furthermore, in certain embodiments, the labeling and termination steps are performed separately. According to the methods of the invention, labeling and termination reactions are performed downstream from the target position. According to the methods of the invention, an unlabelled terminator nucleotide is preferably provided to prevent extension of primers hybridized adjacent to a wild-type nucleotide at a target position suspected of containing a variation. Accordingly, background due to extension through the wild-type nucleotide at the target position is reduced or essentially eliminated.

[0080] Accordingly, preferred methods of the invention comprise providing a primer that specifically hybridizes to a target nucleic acid upstream (5′) from a target position suspected of being variant. The hybridized primer is preferably extended in the presence of unlabeled nucleotides that are only incorporated if a variation is present at the target position, and in the essential absence of unlabeled nucleotides that are incorporated if a wild-type nucleotide is present at the target position. An extended primer containing a variant sequence is labeled by further extending the primer in the presence of a labeled nucleotide that is complementary to a wild-type nucleotide at a labeling position downstream (3′) (preferably immediately downstream) from the target position. One of ordinary skill in the art will appreciate that the labeled nucleotide is preferably not complementary to the wild-type nucleic acid at the target position. The labeled nucleotide may be an extension nucleotide or alternatively a terminator nucleotide. In one embodiment, the labeled extension product is terminated by including a terminator nucleotide that is complementary to a wild-type nucleotide downstream from the labeling position. One of ordinary skill in the art will appreciate that this terminator nucleotide is preferably not complementary to the variation at the target position or the wild-type nucleotide at the labeling position. Preferably, in order to reduce background labeling due to incorrect extension through a wild-type nucleotide at the target position, an unlabeled terminator complementary to the wild-type nucleotide at the target position is added to cap primers hybridized to wild-type target nucleic acids. In one embodiment, the unlabeled terminator used for capping primers hybridized to wild-type nucleic acids is the same as the terminator that terminates extension of the labeled variant extension products.

[0081] The label is preferably a fluorescent tag. Alternatively a radioactive isotope, a molecular weight tag or other detectable label may be incorporated. Various labels are commonly used by those skilled in the art.

[0082] Detection and Analysis of the Extension Product

[0083] While unlabeled primer extension products are contemplated, in preferred methods of the invention, only extension products that have been extended through the region suspected of containing a variation, such as a deletion, are analyzed, because they are the only extension products that contain a detectable label according to the preferred methods of the invention.

[0084] Extended primer products are preferably detected using methods known in the art for detecting labeled oligonucleotides. In some embodiments, useful methods include gel electrophoresis, mass spectroscopy, capillary electrophoresis, sequencing, and other methods for determining the differential length of two primers.

[0085] The following examples illustrate practice of the invention using mutation detection in various loci on samples prepared from biological specimens. Also, below are certain illustrative examples of primer extension assays used to detect variations in a biological sample, and therefore diagnose disease in a patient from whom the sample is obtained.

Example 2 Read-Through Primer Extension Protocol

[0086] A typical read-through primer extension reaction is shown as follows: ˜XXXXXXXX-N₁-N₂*-T (extended primer sequence) ˜XXXXXXXX-X-X-X (extended product on the template sequence)

[0087] In the extended primer, N₁ is an unlabeled deoxynucleotide triphosphate, N₂* is a labeled deoxynucleotide triphosphate (the identity of this labeled nucleotide is preferably different from the unlabeled nucleotide), T is an unlabeled terminator (e.g. unlabeled dideoxynucleotide triphosphate), and X represents an unspecific nucleotide that is defined by the sequence of the target template sequence to which the primer is designed to hybridize.

[0088] The unspecific nucleotides in the template sequences can be, for example, A, C, G, or T, and the sequence of the primer is designed to hybridize with the template sequence according to standard Watson-Crick base-pairing rules. The unlabeled deoxynucleotide triphosphate, labeled deoxynucleotide triphosphate, and unlabeled terminator (e.g. unlabeled dideoxynucleotide triphosphate) are added in a primer extension reaction such that the unique bases are added according to the sequence shown by the formula provided above (i.e.,˜N₁-N₂*-T) for a given mutation, wherein the identity of N₁ and N₂ are preferably different.

[0089] In a typical reaction, a 5 μl extension reaction is performed and the extension products are analyzed by capillary electrophoresis. A typical 5 μl reaction contains 1 μl of 10× reaction buffer, 1 μl of 5 μM primer, 0.05 μl of thermal sequencing enzyme (e.g. thermosequenase at 32U/μl), 1 μl of each unlabeled terminator or extension nucleotide (50 μM) that is included in the reaction, and 0.05 μl of each labeled terminator or extension nucleotide that is included in the reaction. Water is added to generate a 5 μl reaction.

Example 3 Variation Detection at APC (876)

[0090] Variants or mutants are detected at APC (876) using a primer with a sequence that is shown underlined in the following a APC nucleotide sequence: (SEQ ID NO:23) ggcaacatgactgtcctttcaccatatttgaatactacagtgttacccagctcctcttcatcaagaggaagcttagatagttctcgttctgaaaaa gatagaagtttggagagagaacgcggaattggtctaggcaactaccatccagcaacagaaaatccaggaacttcttcaaagggaggtttgc agatctccaccactgcagcccagattgccaaagtcatggaagaagtgtcagccattcatacctctcaggaagacagaagttctgggtctacc actgaattacattgtgtgacagatgagagaaatgcacttagaagaagctctgctgcccatacacattcaaacacttacaatttcactaagtcgg aaaattcaaataggacatgttctatgccttatgccaaattaga

[0091] The following primer and extension product sequences are shown in a 5′ to 3′ orientation. The following nucleic acid primer and nucleotides are added to the extension reaction: Nucleic Acid Primer (P1): atccaggaacttcttcaaag (SEQ ID NO:24) Nucleotides: 1. Unlabeled deoxyguanosine triphosphate (dGTP) (“g”) 2. Labeled dideoxyadenosine triphosphate (ddATP) (a*)

[0092] The following extension products are obtained for wild type (wt) and mutant (mt) templates: wt-atccaggaacttcttcaaaggga* (SEQ ID NO:25) mt-atccaggaacttcttcaaaga* (SEQ ID NO:26)

Example 4 Variation Detection at APC (1554)

[0093] Variants or mutants are detected at APC (1554) using a primer with a sequence that is shown underlined in the following a APC nucleotide sequence: (SEQ ID NO:27) tctgagcctcgatgagccatttatacagaaagatgtggaattaagaataatgcctccagttcaggaaaatgacaatgggaatgaaacagaatc agagcagcctaaagaatcaaatgaaaaccaagagaaagaggcagaaaaaactattgattctgaaaaggacctattagatgattcagatgat gatgatattgaaatactagaagaatgtattatttctgccatgccaacaaagtcatcacgtaaaggcaaaaagccagcccagactgcttcaaaat tacctccacctgtggcaaggaaaccaagt

[0094] The following primer and extension product sequences are shown in a 5′ to 3′ orientation. The following nucleic acid primer and nucleotides are added to the extension reaction: Nucleic Acid Primer (Q1): agagaaagaggcagaaaaaa (SEQ ID NO:28) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Unlabeled deoxyguanosine triphosphate (dGTP) (“g”) 4. Labeled deoxythymidine triphosphate (dTTP) (“t*”)

[0095] The following extension products are obtained for wild type (wt) and mutant (mt) templates: wt-agagaaagaggcagaaaaaac (SEQ ID NO:29) mt-agagaaagaggcagaaaaaaat*t*gat*t*c (SEQ ID NO:30)

EXAMPLE 5 Mutation Detection at APC

[0096] Other variants or mutants are detected at the APC locus by interrogating amplicons generated by amplification using forward (For) and reverse (Rev) primers and the amplicons are captured by hybridization (Amplicon B is 188 bp long and is generated using B-For tgtagttcattatcatcttt (SEQ ID NO: 31) and B-Rev cttcgcacacaggatcttca (SEQ ID NO: 32), Amplicon C is 185 bp long and is generated using C-For aggcacaaagctgttgaat (SEQ ID NO: 33) and C-Rev tatcaagtgaactgacaga (SEQ ID NO: 34), Amplicon D is 188 bp long and is generated using D-For cacctccaccacctcctcaa (SEQ ID NO: 35) and D-Rev gtatcagcatctg (SEQ ID NO: 36)).

[0097] Variants can be detected in the following reactions using the following primers and nucleotides. The variants are detected as the presence of the following mutant (mt) extension products: Reaction I: Nucleic Acid Primer (B1): aaatagcagaaataaaa (B1) (SEQ ID NO:37) Nucleotides: 1. Unlabeled deoxyguanosine triphosphate (dGTP) (“g”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Labeled dideoxythymidine triphosphate (ddTTP) (“t*”) Extension Products: wt-aaataagcagaaataaaaggaaagat* (SEQ ID NO:38) mt-aaatagcagaaataaaagat* (SEQ ID NO:39) Reaction II: Nucleic Acid Primer (B3): tccaatcttttcttttattt (SEQ ID NO:40) Option 1: Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxyadenosine triphosphate (ddATP) (“a*”) Extension Products: wt-tccaatcttttcttttatttc (SEQ ID NO:41) mt1-tccaatcttttcttttattta* (SEQ ID NO:42) Option 2: Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxyguanosine triphosphate (ddGTP) (“g*”) Extension Products: wt-tccaatcttttcttttatttc (SEQ ID NO:43) mt2-tccaatcttttcttttatttg* (SEQ ID NO:44) Option 3 Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxythymidine triphosphate (ddTTP) (“t*”) Extension Products: wt-tccaatcttttcttttatttct (SEQ ID NO:45) mt-tccaatcttttcttttatttt (SEQ ID NO:46) Reaction III: Nucleic Acid Primer (B4): atcttcagctgactagttc (SEQ ID NO:47) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Labeled deoxythymidine triphosphate (dTTP) (“t*”) Extension Products: wt-atcttcagctgactagttcc (SEQ ID NO:48) mt-atcttcagctgactagttcat*t*t*t*at*t*t*c (SEQ ID NO:49) Reaction IV: Nucleic Acid Primer (C1): ctccctcaaaagtggtgct (SEQ ID NO:50) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 3. Labeled deoxyadenosine triphosphate (dATP) (“a*”) Extension Products: wt-ctccctcaaaagtggtgctc (SEQ ID NO:51) mt-ctccctcaaaagtggtgctta* (SEQ ID NO:52) Reaction V: Nucleic Acid Primer (c2): gtccacctgaacactatgtt (SEQ ID NO:53) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 3. Labeled deoxyadenosine triphosphate (dATP) (“a*”) Extension Products: wt-gtccacctgaacactatgttc (SEQ TD NO:54) mt-gtccacctgaacactatgttta* (SEQ ID NO:55) Reaction VI: Nucleic Acid Primer (c3): gctaaacatgagtggggt (SEQ ID NO:56) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Labeled deoxythymidine triphosphate (dTTP) (“t*”) Extension Products: wt-gctaaacatgagtggggtc (SEQ ID NO:57) mt-gctaaacatgagtggggtat*c (SEQ ID NO:58) Reaction VII: Nucleic Acid Primer (D1): ctcaaacagctcaaaccaag (SEQ ID NO:59) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 3. Labeled deoxyguanosine triphosphate (dGTP) (“g*”) Extension Products: wt-ctcaaacagctcaaaccaagc (SEQ ID NO:60) mt-ctcaaacagctcaaaccaagtg* (SEQ lID NO:61) Reaction VIII: Nucleic Acid Primer (D3): tgcttaggtccactttctct (SEQ ID NO:62) Nucleotides: 1. Labeled dideoxycytosine triphosphate (ddCTP) (“c*”) 2. Unlabeled deoxythyrnidine triphosphate (dTTP) (“t”) Extension Products: wt-tgcttaggtccactttctctc* (SEQ ID NO:63) mt-tgcttaggtccactttctcttttttc* (SEQ ID NO:64)

Example 6 Variation Detection at Kras Cp2

[0098] Variants are detected at the HUMRASK02 (exon1) by interrogating amplicons generated by amplification using forward (For) and reverse (Rev) primers and the amplicons are captured by hybridization (Amplicon A is 242 bp long and is generated using A-For cctgctgaaaatgactgaa (SEQ ID NO: 65) and A-Rev tatgaaaatggtcagagaaa (SEQ ID NO: 66)).

[0099] Variants can be detected in the following reactions using the following primers and nucleotides. The variants are detected as the presence of the following mutant (mt) extension products: Reaction I: Nucleic Acid Primer (A1): aacttgtggtagttggagct (SEQ ID NO:67) Option 1: Nucleotides: 1. Unlabeled deoxyguanosine triphosphate (dGTP) (“g”) 2. Labeled dideoxyadenosine triphosphate (ddATP) (“a*”) Extension Products: wt-aacttgtggtagttggagctgg (SEQ ID NO:68) mt1-aacttgtggtagttggagcta* (SEQ ID NO:69) Option 2. Nucleotides: 1. Unlabeled deoxyguanosine triphosphate (dGTP) (“g”) 2. Labeled dideoxycytosine triphosphate (ddCTP) (“c*”) Extension Products: wt-aacttggtggtagttggagctgg (SEQ ID NO:70) mt2-aacttgtggtagttggagctc* (SEQ ID NO:71) Option 3: Nucleotides: 1. Unlabeled deoxyguanosine triphosphate (dGTP) (“g”) 2. Labeled dideoxythymidine triphosphate (ddTTP) (“t*”) Extension Products: wt-aacttgtggtagttggagctggt* (SEQ ID NO:72) mt-aacttgtggtagttggagctt* (SEQ ID NO:73) Reaction II: Nucleic Acid Primer (A2 rev): ggcactttgcctacgcca (SEQ ID NO:74) Option 1. Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxythymidine triphosphate (ddTTP) (“t*”) Extension Products: wt-ggcactttgcctacgccacc (SEQ ID NO:75) mt1-ggcactttgcctacgccat* (SEQ ID NO:76) Option 2: Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxyguanosine triphosphate (ddGTP) (“g*”) Extension Products: wt-ggcactttgcctacgccacc (SEQ ID NO:77) mt2-ggcactttgcctacgccag* (SEQ ID NO:78) Option 3: Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxyadenosine triphosphate (ddATP) (“a*”) Extension Products: wt-acttgtggtagttggagctgcca* (SEQ ID NO:79) mt-acttgtggtagttggagctga* (SEQ ID NO:80) Reaction III: Nucleic Acid Primer (A3 rev): aaggcactttgcctacg (SEQ ID NO:81) Option 1: Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxyguanosine triphosphate (ddGTP) (“g*”) Extension Products: wt-aaggcactttgcctacgcc (SEQ ID NO:82) mt1-gaaggcactttgcctacgg* (SEQ ID NO:83) Option 2: Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxythymidine triphosphate (ddTTP) (“t*”) Extension Products: wt-aaggcactttgcctacgcc (SEQ ID NO:84) mt2-gaaggcactttgcctacgt* (SEQ ID NO:85) Option 3: Nucleotides: 1. Unlabeled deoxycytosine triphosphate (dCTP) (“c”) 2. Labeled dideoxyadenosine triphosphate (ddATP) (“a*”) Extension Products: wt-ggggcactttgectacgcca* (SEQ ID NO:86) wt-aaggcactttgcctacga* (SEQ ID NO:87)

Example 7 Variation Detection at p53 (HSP53)

[0100] Variants or mutants at the p53 locus are detected by interrogating amplicons generated by amplification using forward (For) and reverse (Rev) primers and the amplicons are captured by hybridization (Amplicon E is 203 bp long and is generated using E-For ccatctacaagcagtc (SEQ ID NO: 88) and E-Rev cagacctaagagcaatca (SEQ ID NO: 89), Amplicon F is 229 bp long and is generated using F-For taccaccatccactacaa (SEQ ID NO: 90) and F-Rev taccttctttagccatt (SEQ ID NO: 91), Amplicon G is 226 bp long and is generated using G-For ctgcctcttgcttctctttt (SEQ ID NO: 92) and G-Rev tgcttgcttacct (SEQ ID NO: 93)).

[0101] Variants can be detected in the following reactions using the following primers and nucleotides. The variants are detected as the presence of the following mutant (mt) extension products: Reaction I: Nucleic Acid Primer (E1): catgacggaggttgtgaggc (SEQ ID NO:94) An A or T mutation is detected. Nucleotides: 1. Unlabeled dideoxyguanosine triphosphate (ddGTP) (“g”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 4. Labeled deoxycytosine triphosphate (dCTP) (“c*”) Extension Products: wt-catgacggaggttgtgaggcg (SEQ ID NO:95) mt-ggtgacggaggttgtgaggcac*tg (SEQ ID NO:96) mt-catgacggaggttgtgaggctc*tg (SEQ ID NO:97) Reaction II: Nucleic Acid Primer (F1 rev): ggatgggcctcggttcatgc (SEQ ID NO:98) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 3. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 4. Labeled deoxyguanosine triphosphate (dGTP) (“g*”) Extension Products: wt-ggatgggcctcggttcatgcc (SEQ ID NO:99) mt1-ggatgggcctcggttcatgcag*c (SEQ ID NO:100) mt2-ggatgggcctcggttcatgctg*c (SEQ ID NO:101) Reaction III: Nucleic Acid Primer (F2): gtaacagttcctgcatgggcg (SEQ ID NO:102) Nucleotides: 1. Unlabeled dideoxyguanosine triphosphate (ddGTP) (“g”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 4. Labeled deoxycytosine triphosphate (dCTP) (“c*”) Extension Products: wt-gtaacagttcctgcatgggcgg (SEQ ID NO:103) mt-gtaacagttcctgcatgggcgac*atg (SEQ ID NO:104) mt-gtaacagttcctgcatgggcgtc*atg (SEQ ID NO:105) Reaction IV: Nucleic Acid Primer (F3): cctgcatgggcggcatgaac (SEQ ID NO:106) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 3. Labeled deoxyguanosine triphosphate (dGTP) (“g*”) Extension Products: wt-cctgcatgggcggcatgaacc (SEQ ID NO:107) mt-cctgcatgggcggcatgaactg*g* (SEQ ID NO:108) Reaction V: Nucleic Acid Primer (F4 rev): gatggtgaggatgggcctc (SEQ ID NO:109) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 3. Labeled deoxyguanosine triphosphate (dGTP) (“g*”) Extension Products: wt-gatggtgaggatgggcctcc (SEQ ID NO:110) mt-gatggtgaggatgggcctctg*g*ttc (SEQ ID NO:111) Reaction VI: Nucleic Acid Primer (G1): gacggaacagctttgagg (SEQ ID NO:112) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 4. Labeled deoxyguanosine triphosphate (dGTP) (“g*”) Extension Products: wt-gacggaacagctttgaggc (SEQ ID NO:113) mt-gacggaacagctttgaggag*c (SEQ ID NO:114) mt-gacggaacagctttgaggtg*c (SEQ ID NO:115) Reaction VII: Nucleic Acid Primer (G2): acggaacagctttgaggtgc (SEQ ID NO:116) Nucleotides: 1. Unlabeled dideoxyguanosine triphosphate (ddGTP) (“g”) 2. Unlabeled deoxyadenosine triphosphate (dATP) (“a”) 3. Labeled deoxythymidine triphosphate (dTTP) (“1*”) Extension Products: wt-acggaacagctttgaggtgcg (SEQ ID NO:117) mt-acggaacagctttgaggtgcat*g (SEQ ID NO:118) Reaction VIII: Nucleic Acid Primer (G3): gtgcctgtcctgggagagac (SEQ ID NO:119) Nucleotides: 1. Unlabeled dideoxycytosine triphosphate (ddCTP) (“c”) 2. Unlabeled deoxythymidine triphosphate (dTTP) (“t”) 3. Labeled deoxyguanosine triphosphate (dGTP) (“g*”) Extension Products: wt-gtgcctgtcctgggagagacc (SEQ ID NO:120) wt-gtgcctgtcctgggagagactg*g*c (SEQ ID NO:121)

Example 8 Mutations Detected in Various Sites on a Target Gene

[0102] Table 2 identifies certain mutations that are detected for various sequences that are specific to a particular site on a gene. In addition, the chart identifies the type of mutation that is associated with the mutant sequence. These sequences that have been identified are used according to the methods of the invention to detect and diagnose disease, such as colorectal cancer, in a non-invasive procedure. TABLE 2 SEQ Mutations Gene Site Mutation Type Sequence (5′ to 3′) ID NO: Detected k-ras K12p1 Point Mutation Aacttgtggtagttggagct 122 G to A, C, or T k-ras K12p2 Point Mutation Acttgtggtagttggagctg 123 G to A, C, or T k-ras K13p2 Point Mutation Tgtggtagttggagctggtg 124 G to A, C, or T APC 1309 Deletion Aaatagcagaaataaaa 125 2-5 bp Deletions APC 1306 Point Mutation Tccaatcttttcttttattt 126 G to A, C, or T APC 1312 Point Mutation Atcttcagctgacctagttc 127 G to T APC 1367 Point Mutation Ctccctccaaaagtggtgct 128 C to T APC 1378 Point Mutation Gtccacctgtacactatgtt 129 C to T APC 1379 Point Mutation Cctaaacataagtggggtct 130 G to T APC 1450 Point Mutation Ctcaaacagcacaaaccaag 131 C to T APC 1465 Point Mutation Tgcttaggcccactttctct 132 G to A (Deletion) P53 175p2 Point Mutation Catgacggaggttgtgaggc 133 G to A or T P53 245p1 Point Mutation Gtaacagttcctgcatgggc 134 G to A or T P53 245p2 Point Mutation Taacagttcctgcatgggcg 135 G to A or T P53 248p1 Point Mutation Cctgcatgggcggcatgaac 136 C to T P53 248p2 Point Mutation Ctgcatgggcggcatgaacc 137 G to A P53 273p1 Point Mutation Gacggaacagctttgaggtg 138 C to T P53 273p2 Point Mutation Acggaacagctttgaggtgc 139 G to A P53 282 Point Mutation Gtgcctatcctgggagagac 140 C to T Bat26 Bat26 Deletion Gcccttaacctttttcaggt 141 4-15 bp Deletion APC 876 Point Mutation Ggtggagatctgcaaacctc 142 C to T APC 1554 Point Mutation agagaaagaggcagaaaaaa 143 C to A

Example 9 Primer Sequences for DNA Integrity Analysis

[0103] Table 3 identifies particular DNA integrity assay primer sequences, along with a label (if any). Also provided are the lengths of these primer sequences. Furthermore, as the Oligo Name Bases having a “XXX-D-XXX” designation refers to those DNA integrity primer sequences related to APC. Also, the Oligo Name Bases having a “XXX-E-XXX” designation refers to those DNA integrity primer sequences related to p53. Furthermore, Table 3 shows useful capture sequences, along with a label that are used according to the methods of the invention. TABLE 3 Oligo Name SEQ ID Bases Sequence 5′-3′ Label NO: PCR-D-FOR gcggtcccaaaagggtcagtcacctccaccacctcctcaa N/A 144 200-D-REV gcggtcccaaaagggtcagtgtatcagcatctggaagaa 5′-Biotin 145 400-D-REV gcggtcccaaaaggtcagtcatcatcatctgaatcatct 5′-Biotin 146 800-D-REV gcggtcccataagggtcagttcacctgactgtgctcctcc 5′-Biotin 147 1.3-D-REV gcggtccctaaagggtcagtttggctgctttgcaatagctt 5′-Biotin 148 1.8-D-REV gcggtcccataagggtcagtttggcattgcggagcttatac 5′-Biotin 149 2.4-D-REV gcggtcccaaaagggtcagtggcttaattctgatttcaca 5′-Biotin 150 PCR-E-FOR gcggtcccaaaagggtcagtccatctacaagcagtca N/A 151 PCR-E-FOR gcggtcccaaaagggtcagtcagacctaagagcaatca 5′-Biotin 152 400-E-REV gcggtcccaaaagggtcagtcccatttactttgcacatct 5′-Biotin 153 800-E-REV gcggtcccaaaagggtcagtcccatgcaggaactgtt 5′-Biotin 154 1.3-E-REV gcggtcccaaaagggtcagagtatggaagaaateggtaa 5′-Biotin 155 (same sequence as PCR-F-REV) 1.8-E-REV gcggtcccaaaagggtcagtagcatctgtatcaggcaaag 5′-Biotin 156 2.4-E-REV gcggtccgaaaagggtcagtgggcaacagagcaagatg 5′-Biotin 157 Capture Sequences CAP-E cagatagccctggacaaaccatgccaccaagcagaag 5′-Biotin 158 CAP-E tactcccctgccctcaacaagatgttttgccaactgg 5′-Biotin 159

[0104] The CAP-D designation refers to APC, and the CAP-E designation refers to p53. Also, the Oligo Name Bases also refers to the expected band sizes for the associated DIA primer sequence. For example, the labeled primer sequence having the “1.3-D-REV” Oligo Name Base designation may expect the detection of a nucleic acid fragment having a length of 1.3 Kb. The capture probe sequences that are used according to the methods of the invention are shown in Table 1 above. Certain of the capture probe sequences may be cross-references to various capture probes provided in the Examples herein.

[0105] In general, capture probes are preferably biotinylated so that they can be purified (along with the capture nucleic acids) using, for example, steptavidin coated beads according to the methods known in the art. Also, sequences may be purified and detected according to other methods commonly known to those skilled in the art.

Example 10 Internal Control Samples for Primer Extension Reactions

[0106] As illustrated in Table 4, mutant, wild-type and internal controls with a one base difference at the mutation site and a different labeled acyclo nucleotide were used to distinguish mutant from internal control samples. TABLE 4 Site: A1 Sequence with different labeled Sequence type acyclo nucleotide SEQ ID NO: Mutant AacttgtggtagttggagctT 160 Wildtype AacttgtggtagttggagctG 161 Internal control AacttgtggtagttggagctC 162

[0107] R110 acyclo-TTP, Tamra acyclo-CTP and unlabeled ddGTP were used in the reaction cocktail. Samples were generated with oligo controls by making 2%,1% mutant and 100% wildtype and all samples were mixed with 1% of the internal control. Four reaction conditions were tested using two different dilutions (1:20 and 1:100, Table 5, T is the mutant nucleotide and C is the control nucleotide) of the labeled nucleotides to see how this influences variability. The results of these reactions are shown in FIG. 1. TABLE 5 T1_20 C1_20 T1_20 C1_100 T1_100 C1_20 T1_100 C1_100

[0108] Using the same labeled terminator for the internal control and sample eliminates variability of replicates as well as sample to control ratios for different terminator lots, as illustrated in FIG. 2. Using the same lot of labeled nucleotide for the internal control and sample will correct for lot fluctuations, and it is therefore a valid method to use absolute ratios (sample-to-control) in the determination of whether a sample is positive or negative.

Example 11 Single Base Extension Mutant Detection Reactions

[0109] The following primers are used in single base extension reactions to detect mutations at the loci described in Examples 1-10 above. The nucleotide used for blocking each extension reaction is preferably a terminator nucleotide such as a ddNTP or an acyclo terminator. The labeled nucleotide that is incorporated in the presence of a mutation also is preferably a terminator nucleotide such as a labeled ddNTP or an acyclo terminator Preferably the extension reaction is repeated several times by cycling the reaction between extension and denaturing temperatures for 5 to 50 cycles, more preferably for 10 to 40 cycles, and more preferably for about 20 to 30 cycles. TABLE 6 SBE primer Sequence SEQ. ID NO: (A1 SBE) Aacttgtggtagttggagct 163 (A2 SBE) Acttgtggtagttggagctg 164 (A3 SBE) Tgtggtagttggagctggtg 165 (B1 SBE) Aaatagcagaaataaaa 166 (B1 SBE) Aaatagcagaaataaaa 167 (B3 SBE) Tccaatcttttcttttattt 168 (B4 SBE) Atcttcagctgacctagttc 169 (C1 SBE) Ctccctccaaaagtggtgct 170 (C2 SBE) Gtccacctgtacactatgtt 171 (C3 SBE) Gctaaacataagtggggtct 172 (D1 SBE) Ctcaaacagcacaaaccaag 173 (D3 SBE) Tgcttaggcccactttctct 174 (E1 SBE) Catgacggaggttgtgaggc 175 (F1 SBE) Gtaacagttcctgcatgggc 176 (F2 SBE) Taacagttcctgcatgggcg 177 (F3 SBE) Cctgcatgggcggcatgaac 178 (F4 SBE) Ctgcatgggcggcatgaacc 179 (G1 SBE) Gacggaacagctttgaggtg 180 (G2 SBE) Acggaacagctttgaggtgc 181 (G3 SBE) Gtgcctatcctgggagagac 182 (P1 SBE) Ggtggagatctgcaaacctc 183 (Q1 SBE) Agagaaagaggcagaaaaaa 184 (J1 BAT-26) Gcccttaacctttttcaggt 185

[0110] The following reaction conditions were used for the different single base extension primers (SBE primers) shown in Table 6:

[0111] Reaction I: Nucleic Acid SBE Primers A1, A2 and A3 (Kras Cp2)

[0112] Three separate 5 μl reactions were run for each primer, each reaction including 5 μM primer, 10× reaction buffer, Acyclopol polymerase, and water as described above. Each reaction also included the following nucleotides:

[0113] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0114] 2. Labeled terminator (R110-dd or R110-acylco ATP)

[0115] 3. Labeled terminator (R110-dd or R110-acylco CTP)

[0116] 4. Labeled terminator (R110-dd or R110-acylco TTP)

[0117] Reaction II: Nucleic Acid Primer B1 (APC 1309)

[0118] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), 0.15 μl Thermosequenase, 1.775 μL water. Each reaction also included the following nucleotides:

[0119] Nucleotides: 1. 2 mM Unlabeled deoxyadenosine triphosphate/deoxyguanosine triphosphate (dATP/dGTP)

[0120] 2. Labeled terminator (R110-dd or R110-acylco TTP)

[0121] Reaction III: Nucleic Acid SBE Primer B3 (APC 1306)

[0122] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), 1.825 μL water. Each reaction also included the following nucleotides:

[0123] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0124] 2. Labeled terminator (R110-dd or R110-acylco ATP)

[0125] 3. Labeled terminator (R110-dd or R110-acylco GTP)

[0126] 4. Labeled terminator (R110-dd or R110-acylco TTP)

[0127] Reaction IV: Nucleic Acid SBE Primer B4 (APC 1312)

[0128] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), 0.925 μL water. Each reaction also included the following nucleotides:

[0129] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0130] 2. 50 μM Unlabeled terminator (dd or acyclo TTP)

[0131] 3. Labeled terminator (R110-dd or R110-acylco ATP)

[0132] Reaction V: Nucleic Acid SBE Primers C1 and C2 (APC)

[0133] Two separate reactions were run for each primer, each reaction including 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and water. Each reaction also included the following nucleotides:

[0134] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo ATP)

[0135] 2. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0136] 3. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0137] 4. Labeled terminator (R110-dd or R110-acylco TTP)

[0138] Reaction VI: Nucleic Acid SBE Primer C3 (APC)

[0139] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), 1.925 μL water. Each reaction also included the following nucleotides:

[0140] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0141] 2. Labeled terminator (R110-dd or R110-acylco ATP)

[0142] Reaction VII: Nucleic Acid SBE Primers D1 and D3 (APC)

[0143] Two separate reactions were run for each primer, each reaction including 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), 1.825 μL water. Each reaction also included the following nucleotides:

[0144] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo ATP)

[0145] 2. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0146] 3. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0147] 4. Labeled terminator (R110-dd or R110-acylco TTP)

[0148] Reaction VIII: Nucleic Acid SBE Primer E1, F1 and F2 (p53)

[0149] Three separate reactions were run, each of which including 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and 0.875 μL water. Each reaction also included the following nucleotides:

[0150] Nucleotides: 1. 50 μM terminator (dd or acyclo CTP)

[0151] 2. 50 μM terminator (dd or acyclo GTP)

[0152] 3. Labeled terminator (R110-dd or R110-acylco ATP)

[0153] 4. Labeled terminator (R110-dd or R110-acylco TTP)

[0154] Reaction IX: Nucleic Acid SBE Primer F3 (p53)

[0155] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and water. Each reaction also included the following nucleotides:

[0156] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo ATP)

[0157] 2. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0158] 3. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0159] 4. Labeled terminator (R110-dd or R110-acylco TTP)

[0160] Reaction X: Nucleic Acid SBE Primer F4 (p53)

[0161] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and water. Each reaction also included the following nucleotides:

[0162] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0163] 2. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0164] 3. 50 μM Unlabeled terminator (dd or acyclo TTP)

[0165] 4. Labeled terminator (R110-dd or R110-acylco ATP)

[0166] Reaction XI: Nucleic Acid SBE Primer G1 (p53)

[0167] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and 0.875 μL water. Each reaction also included the following nucleotides:

[0168] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0169] 2. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0170] 3. Labeled dideoxyadenosine triphosphate (R110-ddATP)

[0171] 4. Labeled terminator (R110-dd or R110-acylco TTP)

[0172] Reaction XII: Nucleic Acid SBE Primer G2 (p53)

[0173] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and 1.925 μL water. Each reaction also included the following nucleotides:

[0174] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0175] 2. Labeled terminator (R110-dd or R110-acylco ATP)

[0176] Reaction XIII: Nucleic Acid SBE Primer G3 (p 53)

[0177] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and 1.925 μL water. Each reaction also included the following nucleotides:

[0178] Nucleotide: 1. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0179] 2. Labeled terminator (R110-dd or R110-acylco TTP)

[0180] Reaction XIV: Nucleic Acid Primer J1 (BA T-26)

[0181] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), 0.01 μL Thermo sequenase, and water. Each reaction also included the following nucleotides:

[0182] Nucleotides: 1. 2 mM Unlabeled deoxyadenosine triphosphate (dATP)

[0183] 2. Labeled terminator (R110-dd or R110-acylco GTP)

[0184] Reaction XV: Nucleic Acid SBE Primers P1 and Q1 (APC)

[0185] A 5 μl extension reaction included 5 μM primer, 10× reaction buffer, 0.025 μL Acyclopol (32 U/μL), and water. Each reaction also included the following nucleotides:

[0186] Nucleotides: 1. 50 μM Unlabeled terminator (dd or acyclo CTP)

[0187] 2. 50 μM Unlabeled terminator (dd or acyclo GTP)

[0188] 3. 50 μM Unlabeled terminator (dd or acyclo TTP)

[0189] 4. Labeled dideoxyadenosine triphosphate (R110-ddATP) 

We claim:
 1. A method for detecting a variant in a primer extension assay, the method comprising the steps of: a) contacting a target nucleic acid with a nucleic acid primer complementary to a region of said target nucleic acid; and b) extending said primer in the presence of: i) a first nucleotide that is complementary to a first variant nucleotide suspected to be at a position downstream of said region; and, ii) a second nucleotide that is complementary to a second variant nucleotide at said position, thereby to reduce misincorporation of said first nucleotide on a template comprising said second variant nucleotide..
 2. The method of claim 1 wherein said first nucleotide is a terminator nucleotide.
 3. The method of claim 1 wherein said second nucleotide is a terminator nucleotide.
 4. The method of claim 2 wherein said first nucleotide is labeled.
 5. The method of claim 3 wherein said second nucleotide is labeled.
 6. The method of claim 1 comprising the step of adding a plurality of terminator nucleotides, wherein each of said nucleotides is complementary to a variant suspected to be present in said target nucleic acid.
 7. The method of claim 1 wherein said first nucleotide is an extension nucleotide.
 8. The method of claim 1 wherein the sequence of said region in said target nucleic acid is a wild-type sequence.
 9. The method of claim 1 wherein said target nucleic acid is a genetic locus selected from the group consisting of BAT26, APC, DCC, P53 and RAS.
 10. The method of claim 1 wherein said target nucleic acid is a genetic locus associated with cancer or precancer.
 11. The method of claim 1 wherein said cancer or precancer is a colorectal cancer or precancer.
 12. The method of claim 1 wherein said target nucleic acid sequence is obtained from a heterogeneous biological sample.
 13. The method of claim 12 wherein said biological sample is a stool sample.
 14. The method of claim 12 wherein said biological sample is selected from the group consisting of urine, semen, blood, sputum, cerebrospinal fluid, pus, and aspirate.
 15. The method of claim 13 wherein said stool sample is a homogenized stool sample.
 16. A method for minimizing nucleotide misincorporation in a primer extension assay, the method comprising the steps of: a) contacting a target nucleic acid with a nucleic acid primer complementary to a region of said target nucleic acid; and b) extending said primer in the presence of: i) a first nucleotide that is complementary to a first variant base suspected to be at a position downstream of said region, and a first polymerase that preferentially incorporates said first nucleotide; and, ii) a second nucleotide that is complementary to a second variant base at said position and a second polymerase that preferentially incorporates said second nucleotide, thereby to reduce misincorporation of said first nucleotide in a primer extension reaction at said second variant base.
 17. The method of claim 16, further comprising the step of providing a terminator nucleotide to terminate a primer extension product that incorporates said first nucleotide.
 18. The method of claim 16, wherein said first nucleotide is labeled.
 19. A method for detecting the presence of a variation at a predetermined position in a heterogeneous nucleic acid sample, the method comprising the steps of: a) contacting a target nucleic acid with a nucleic acid primer substantially complementary to said target nucleic acid to form a nucleic acid complex upstream from a predetermined position in said target nucleic acid; and b) contacting said nucleic acid complex with a first nucleotide, a first polymerase, a second nucleotide, and a second polymerase, wherein said first nucleotide is complementary to a first variant base at said predetermined position, and said second nucleotide is complementary to a second variant base at said predetermined position, and wherein said first and second polymerases are different, thereby to reduce misincorporation of said first nucleotide in a primer extension reaction at a said second variant base.
 20. The method of claim 19, wherein said first nucleotide is labeled.
 21. The method of claim 20, wherein said label is a fluorescent label.
 22. The method of claim 19, wherein said first nucleotide is a terminator nucleotide.
 23. The method of claim 22, wherein said second nucleotide is a terminator nucleotide.
 24. The method of claim 20, wherein said terminator nucleotide is labeled.
 25. The method of claim 19, further comprising the step of adding a terminator nucleotide complementary to a nucleotide downstream from said predetermined position.
 26. The method of claim 25, wherein said terminator is labeled.
 27. The method of claim 16 or 19, wherein said first nucleotide is an alkynylamino acycloterminator or analog thereof.
 28. The method of claim 19, wherein said first polymerase preferentially incorporates an alkynylamino acycloterminator or analog thereof.
 29. The method of claim 28 wherein said second polymerase preferentially incorporates a dNTP.
 30. The method of claim 16 wherein said variant is present in about 10% of target nucleic acid molecules in a biological sample.
 31. A kit comprising: a) a first nucleotide, a second nucleotide; and b) a first polymerase adapted for said first nucleotide and a second polymerase adapted for said second nucleotide.
 32. The kit of claim 16 wherein said first nucleotide is an acycloterminator and said second nucleotide is a NTP.
 33. The kit of claim 16 wherein said first polymerase preferentially incorporates acycloterminators and said second polymerase preferentially is a thermostable polymerase that preferentially incorporates dNTPs. 